URINARY SYSTEM DISORDERS
Enuresis
Enuresis is the involuntary passage of urine, usually at nighttime, in a child older than 5 years of age. More commonly, this condition is known as “bed wetting.” Enuresis is more common in boys than in girls. A complete urologic work-up is necessary to discover any physical cause, including severe infection, bladder trauma, diabetes mellitus, small bladder capacity, meatal stenosis (narrowing of the urinary opening), or bladder spasm. Any such physical cause is treated directly. Other possible physical factors may be that the child does not empty the bladder completely on voiding, or that he or she is an exceptionally sound sleeper.
If no physical cause is found, providers will investigate a possible underlying emotional problem. Family stress or school problems are associated with enuresis. Family caregivers should not shame or criticize the child for bed wetting. If the condition persists, low dosages of an antidepressant, such as imipramine hydrochloride (Tofranil), have been used to promote continence. Other medications that may be helpful are flavoxate hydrochloride (Urispas), used in children under age 12; and oxybutynin chloride (Ditropan), used in children over age 5. Counseling can sometimes assist the child and family.
Hemolytic Uremic Syndrome
Hemolytic uremic syndrome (HUS) is an acute condition occurring in children usually between the ages of 1 and 10 years and primarily between the ages of 6 months and 4 years. Three conditions occur in this illness: renal failure, hemolytic anemia, and thrombocytopenia. HUS is the leading cause of acute kidney failure in children.
Cases of HUS are associated with infection by a toxic strain of Escherichia coli (0157:H7). E. coli 0157:H7 is an illness caused by numerous sources, such as contaminated meat, raw milk, raw vegetables, and water. Thorough cooking of meat products is critical in preventing this illness. E. coli can also be transmitted person-to-person because it can be transmitted in diarrheal stools. Proper handwashing is essential.
Hemolytic uremic syndrome usually presents as a flu-like illness and gastroenteritis. Nausea, vomiting, abdominal pain, fever, and bloody diarrhea may be present. Pallor, lethargy, and oliguria typically follow the onset of the milder symptoms. The affected child appears pale, bruised, and hypertensive, with diminished or absent urine output. As the disease progresses, acute renal failure, hemolytic anemia, thrombocytopenia, and microemboli lead to multisystem organ failure. Seizures, disorientation, decreased LOC, and death may follow.
Treatment includes management of hypertension, dialysis, blood transfusions, and nutritional support.
Urinary Obstruction
Urinary obstruction can result from a neoplasm (cancer), calculi (stones), or severe infection. Relieving the obstruction is necessary to prevent complications such as hydronephrosis. Catheterization or antibiotics can be effective; otherwise, surgery is performed.
Urinary Tract Infection
Infection of the urinary tract (UTI) is most commonly caused by perianal microorganisms, most commonly E. coli, and is accompanied by frequency, urgency, and dysuria. The short urethra in the female anatomy contributes to a higher incidence of UTIs in females. Anatomic anomalies may also contribute to the cause of the infection. The occurrence of a UTI in a male warrants urologic evaluation.
Diagnostic evaluation consists of a urine specimen for urinalysis and culture and sensitivity (C&S). Treatment consists of antibiotics, encouraging frequent voiding, and copious fluids. Prevention is the most important goal (see In Practice: Educating the Client 72-4). Children who have chronic UTIs may be maintained on low-dose antibiotics.
Pyelonephritis
Pyelonephritis (pyelitis) is a potentially dangerous infection of the upper urinary tract and kidneys.The causative bacterial infection can migrate to the kidneys by way of the bloodstream or ascend from the bladder because the urinary tract has a mucous membrane.
Symptoms of pyelonephritis include dysuria (painful voiding), urinary frequency and urgency, fever, chills,lower-back pain, and headache. There may be nausea, abdominal tenderness, and pain. C&S tests are done to determine the causative organism so that appropriate antibiotics can be prescribed. Pyelonephritis is curable in most cases if treated promptly.
IN PRACTICE: EDUCATING THE CLIENT 72-4
PREVENTION OF URINARY TRACT INFECTIONS IN FEMALES
• Wipe the perineal area from front to back.
• Wear white cotton panties because they are not irritating and allow good air circulation.
• Do not use bubble bath because it is irritating.
• Drink plenty of fluids.
• Thoroughly rinse soap off the perineum.
• Use white, unscented toilet paper
Glomerulonephritis
Acute glomerulonephritis, also called acute poststreptococcal glomerulonephritis, is the most common form of nephritis found in young children between the ages of 5 and 10 years. It results from an immunologic reaction to infection (most often, streptococcal) elsewhere in the body. Damage to the glomeruli may cause urinary output to decrease or cease.
The initial and main symptom is smoky urine or hematuria. The child’s eyes may be puffy and the blood pressure elevated. A throat culture may reveal GABHS. Kidney enlargement may also be present. Blood tests show mildly to moderately elevated blood urea nitrogen (BUN) and creatinine. The urine shows the presence of RBCs (microscopic or gross hematuria) and elevated WBCs. The urine values, including abnormal protein, indicate impaired renal function. There may be an elevated ASO titer.
The child is kept on bed rest; activity is allowed when the hematuria clears and blood pressure returns to normal. Keep people with URIs away from the child. Provide a diet high in calories and low in sodium, protein, and potassium. Fluids may be restricted. Take daily weights to determine if the child is accumulating fluid in the tissues. Take vital signs regularly and compare new findings with previous readings. Antibiotics and corticosteroids may be prescribed, although the use of steroids is controversial.
In most cases, recovery is complete. In a few cases, chronic nephritis may develop, and the client may need to be maintained on dialysis.
Chronic glomerulonephritis may be a complication of acute glomerulonephritis or may occur without preceding illness. Symptoms are unpredictable, and kidney damage usually is progressive. Chronic glomerulonephritis can lead to hypertension, proteinuria, hematuria, and uremia.
The disease tends to progress in three stages. The first stage is the latent stage, in which the child shows few outward symptoms. Albumin appears in the urine, and the child may be anemic. No special treatment is needed at this time. In the second stage, called the edema stage, the child retains fluid. Treatment includes a high-protein, low-salt diet. Corticosteroid use is controversial; these drugs are sometimes prescribed, but are not as widely used as they once were. In the third stage, the stage of uremia, the child’s kidneys begin to fail. No medical treatment is available for this stage. The child may be maintained on dialysis until a suitable donor for a kidney transplant is located. These children are often excellent candidates for kidney transplantation.
The components of nursing care for clients with chronic glomerulonephritis include:
• Accurate taking and documentation of vital signs, I&O, and daily weight
• Monitoring daily laboratory studies of renal function
• Observing for signs of fluid, electrolyte, and acid-base imbalance
• Encouraging a low-sodium, high-calorie diet with adequate protein
• Providing good skin care (because of itching and edema)
• Providing good oral hygiene (take care not to damage fragile gums)
• Family teaching: the child needs to take medications as ordered and diuretics in the morning so as not to disrupt sleep; report symptoms of UTIs; avoid having the child come into contact with people with URIs
• Explaining to the child and caregivers about side effects of corticosteroids if they are to be given
Nephrotic Syndrome
In nephrotic syndrome, changes in the basement membrane of the glomeruli cause the kidneys to excrete massive amounts of protein. It occurs most often in children between 18 months and 5 years of age and is characterized by generalized edema, proteinuria, and hematuria. Urine output is scanty, and blood pressure is elevated. The abdomen is distended, and the child is uncomfortable. He or she does not eat because fluid in the abdomen and chest causes discomfort. The child is susceptible to other infections.
Palliative measures are symptomatic. Edema is reduced by administering corticosteroids and by limiting fluid and salt intake. Diuretics may be used to reduce edema. Encourage the child to eat. Protect the child against infection. Provide careful skin care and assist the child to move about in bed. If the child is having difficulty breathing, he or she may be more comfortable sitting up.
The child is very ill and needs expert nursing care and emotional support. Corticosteroids may induce a remission, and the prognosis for eventual recovery is good in most cases. Children who respond to steroid therapy have fewer relapses as time progresses. If the disease is diagnosed and treated early, the child can expect to regain normal (or near-normal) renal functioning. Nursing care is similar to that in chronic glomerulonephritis. Check the child’s weight at the same time each day, on the same scale, with the child wearing the same amount of clothing. Monitor vital signs and I&O regularly. During periods of edema, decrease the child’s sodium intake by not adding salt to the diet. A high-protein diet is unnecessary. Do not restrict fluids. Offering frequent small meals (six per day) may help the child’s nutritional intake during periods of exacerbation (flare-up of symptoms). Protect the child from contact with others who have URIs.
Wilms’ Tumor
Wilms’ tumor, also called nephroblastoma, is a malignant adenosarcoma of the kidney. It is most common in children aged 3 to 4 years. One of the most common neoplasms of childhood, it usually affects only one kidney.
In most cases, the child shows no symptoms until the tumor is far advanced. Microscopic hematuria may be present, but usually not until late in the disease’s course. Diagnosis is based on palpation of the abdominal mass, x-ray studies, and biopsy during a laparotomy (surgical exploration of the abdomen).
Treatment for Wilms’ tumor depends on the extent of disease spread. Surgical removal, when done, is followed by irradiation of the tumor site and both sides of the spine. Chemotherapy is often used.
Whenever a child is to have surgery, prepare the family caregivers and child. If the child is old enough to understand, you may use dolls, puppets, and drawings to explain placement of tubes and to play out fears. After surgery, prepare the child and family for the child’s hair loss resulting from chemotherapy.
Nursing Alert When treating a child with Wilms’ tumor, never unnecessarily palpate the abdomen preop-eratively The tumor could rupture and disseminate. Use extreme caution when handling this child at all times. Post a clear warning sign at the child’s bedside.
Hypospadias and Epispadias
In hypospadias, the male child’s urinary meatus is located on the bottom of the penis; in epispadias, the meatus is located on top of the penis. These conditions can usually be surgically corrected and are not life threatening. In severe instances of hypospadias, the newborn’s sex may be in doubt because the position of the meatus may appear to be the female urethra, especially when undescended testes are part of the presentation.
Minor hypospadias is common and usually requires no correction. If surgery is required, it is sometimes done in two stages. Circumcision is contraindicated before surgical correction of this displacement of the urinary meatus because the foreskin may be used for the procedure. Prepare the caregivers intellectually and emotionally for surgery, which is scheduled between 6 and 18 months of age, before the child develops a strong body image.
REPRODUCTIVE SYSTEM DISORDERS
Ambiguous Genitalia
The newborn who exhibits genitalia that seem to have both male and female characteristics is said to have ambiguous genitalia. For instance, in some cases of hypospadias, the newborn’s sex is unclear. If any doubt exists about a baby’s sex, studies are performed immediately. Examiners study the buccal mucosa or skin structure microscopically for a female or male chromosomal pattern. Hormonal and anatomic studies also may be done. Normal social and emotional development demands that a child’s sex be established as soon after birth as possible. Depending on the physical problem, surgery may be necessary to revise or to remove structures. Appropriate hormone administration may also be required.
The term hermaphrodite is used when a child has both testes and ovaries, resulting in malformed external genitalia. The term is often interpreted to mean “half-male and halffemale,” causing confusion and emotional strain for the newborn’s family. Explaining the importance of correct sexual identification, prompt surgery, and hormonal treatment are of foremost importance in helping the family. Encourage the family to give the child an appropriate, gender-specific name and to identify the child as male or female. Urge the family to discuss their concerns with health professionals openly.
Cryptorchidism
Cryptorchidism is an undescended testicle. It is common at birth, but usually corrects itself spontaneously. If not, surgical treatment (orchiopexy) is performed in early childhood to prevent sterility. Because undescended testes are often associated with hernia and hydrocele, surgical repairs are usually completed together. If an undescended testicle is found in an older child, surgery must not be postponed. A delay could result in sterility because sperm cannot tolerate the heat inside the body.
Surgery is usually performed on an outpatient basis. Postoperatively, the child is sent home after bowel sounds return and the child takes and retains fluids, voids, and ambulates properly. The child may return from surgery with an abdominal dressing as a result of accompanying hernia repair. Observe the dressing often for drainage. Teach caregivers what to look for if the child goes home soon after surgery.
Hydrocele
A hydrocele is an accumulation of serous fluid within the scrotal sac, causing the scrotum to become large and painful. If the fluid is not reabsorbed spontaneously, excision and drainage may be necessary. A hydrocele is often associated with a hernia.
NUTRITIONAL CONSIDERATIONS IN YOUNG CHILDREN
Normal growth implies a state of health and absence of a major chronic disease. Growth parameters of height, weight, head circumference (up to 36 months), and body mass index (BMI) should be monitored at each well-child visit and graphed on the appropriate chart. (BMI is the ratio of weight in kilograms divided by the height in meters squared.)
The explosive growth during infancy demands adequate nutrition to facilitate proper growth and development. Protein and fat are especially important for CNS development. Infants require 110 to 120 calories per kilogram of body weight per day for the first 6 months, and 95 to 100 for the remainder of the first year. Human milk has the ideal quality and quantity of nutrients, plus added protection against infections. Commercial formulas supply 20 calories per ounce and are fortified with vitamins and minerals (especially iron). Formula should be fed at room temperature.
The introduction of solid foods may begin at 4 to 6 months of age when the GI tract has matured and is less sensitive to potentially allergenic foods.
The signs of readiness for the introduction of solid foods include:
• The ingestion of 32 ounces of milk daily without hunger satisfaction
• The disappearance of the extrusion reflex (at about 4 months)
• The doubling of birth weight
• The ability to sit unsupported and lean forward with an open mouth to receive food or to lean back and turn the head away, thereby indicating fullness
The order of solid food introduction is not crucial, but rice cereal is usually introduced first, followed by vegetables and fruit. Highly allergenic foods should be avoided. Parents should introduce one new food at a time in small amounts for a period of 5 to 7 days to determine the infant’s response to the food. Solid food should be fed with a spoon and not placed in bottles with formula. As the quantity of solid food increases, the quantity of milk should be decreased to prevent overfeeding. Milk or fruit juice should be introduced in a cup at 6 to 7 months of age, with the goal of weaning completely from the bottle to a cup by 1 year of age to prevent dental caries. Soft, mashed table foods may be introduced gradually.
The toddler’s growth slows, requiring decreased energy and caloric requirements (100 kcal/kg/day). Appetite decreases dramatically (physiologic anorexia), and the desire for selffeeding increases. Introducing finger foods and allowing food choices facilitate independence. Avoid foods that may induce choking, such as round foods (wieners cut into slices), hard foods (e.g., raw carrots), or smooth, sticky foods (e.g., peanut butter). The toddler’s diet should consist of a wide range of nutritious foods from all food groups in small-sized servings and should include nutritious snacks.
The preschool period is not a time of rapid growth and requires only 90 kcal/kg/day. Food fads and strong taste preferences are common. Engaging the child in food preparation and offering food in small portions in an attractive manner promote food acceptance. All snacks should be nutritious and not empty calories. The general consumption of food at this age is about one half of an adult’s portion. Children should never be forced to eat. Preschool children tend to be deficient in zinc, calcium, and iron.
NCLEX Alert Questions on a nursing examination that relate to children often include factors relating to nutrition. Keep in mind that both breast milk and cow’s milk are deficient in iron.
KEY POINTS
• Many childhood communicable diseases can be prevented through immunization.
• Streptococcal infections can lead to serious cardiac complications.
• Parasitic infections generally involve the entire family and home environment.
• The most common cause of injury to a child is trauma.
• SUIDS, including SIDS, is the sudden, unexplained death of an apparently healthy child.
• Abuse must be reported.
• Common skin disorders include nevi, rashes, and eczema.
• Neurologic disorders include Reye’s syndrome and meningitis.
• Meningomyelocele, the most serious form of spina bifida, may cause paralysis or other disorders.
• Hydrocephalus can be detected by OFC measurements.
• Otitis media may require medical or surgical therapies.
• Children with celiac disease must avoid dietary intake of food containing gluten.
• Structural defects of the heart may result in abnormal shunting of oxygenated and deoxygenated blood.
• Leukemias may be acute or chronic.
• Cystic fibrosis is an autosomal recessive disease of the exocrine glands resulting in serious damage to the lungs, pancreas, and liver.
• Serious respiratory tract illnesses include RSV, LTB, epiglottitis, and asthma.
• Illness of the GI tract places the young child at high risk for fluid and electrolyte imbalance or dehydration.
• Urinary tract problems may be structural, autoimmune, cancerous, or infections.
• The most common reproductive disorders are ambiguous genitalia and cryptorchidism.
• Solid foods are generally introduced at 4 to 6 months of age.
